Comment on: Vitrectomy in Small idiopathic MAcuLar hoLe (SMALL) study: conventional internal limiting membrane peeling versus inverted flap

To The Editor:

We read with great interest the recent article titled “Vitrectomy in Small Idiopathic Macular Hole (SMALL) Study: Conventional Internal Limiting Membrane Peeling versus Inverted Flap,” published in Eye by Matteo Fallico et al. [1].

Notably, the inverted flap technique seems to offer no significant advantages over conventional ILM peeling. This finding challenges the growing trend of adopting more complex techniques without clear evidence of their benefits.

Historically, macular hole surgeries did not include ILM peeling; however, successful closures were often reported, particularly in cases of small MHs [2]. The presence of residual vitreous cortex could promote the proliferation of secondary epiretinal membranes. In these instances, the primary role of ILM peeling may be to ensure true and complete posterior vitreous detachment, thereby reducing the risk of secondary complications and enhancing the likelihood of MH closure.

Although the inverted flap technique was initially proposed for MHs larger than 400 microns [3], the definition of “large MH” has since been questioned, suggesting that ILM peeling can effectively address holes exceeding 600 microns [4]. Conversely, in myopic MHs the inverted ILM flap efficacy has been demonstrated regardless of the diameter [5].

While the authors report similar functional outcomes between the two techniques, the inverted ILM flap shows a slight disadvantage in ELM recovery. This difference is clinically marginal, as EZ restoration and visual recovery remain comparable. These observations highlight the need to avoid manoeuvres that may compromise RPE integrity, such as inverted ILM flap insertion. The superiority of ILM flap insertion over covering is unproven [6], and additional surgical manoeuvres may introduce unnecessary risks without clear benefits in managing small macular holes.

In conclusion, given that vitreoschisis plays a pivotal role in the development of MHs, the complete removal of cortical remnants from the macular surface is key to achieving MH closure, provided there is no membrane proliferation on the macula. Therefore, we fully concur with the authors that additional procedures beyond ILM peeling are unnecessary, as the primary objective should be to achieve maximum effectiveness while minimizing potential harm.

Thank you for considering our feedback.

Author contributions

MM wrote the letter. AF, AM, and LF provided feedback on the letter.

Competing interests

The authors declare no competing interests.